Pure elbow dislocation in a child wrestler with underlying hyperlaxity: What is the optimal time to return to competition?

Elbow dislocations are often considered serious injuries that can cause a child athlete to miss the entire season in wrestling. It was reported that the return to sports after the elbow dislocation was between 6 and 12 months in child wrestlers. In some cases, underlying hyperlaxity may have an essential role in the occurrence of pure elbow dislocation without any ligament injury. We report the case of a 10-year-old boy patient who had pure elbow dislocation following falling onto an outstretched hand in a wrestling match. Because the physical examination findings of the patient indicated the presence of hyperlaxity, the patient was treated by closed reduction, short-term immobilization, and early strengthening of the dynamic stabilizers. This case report's findings suggest that detecting the presence of hyperlaxity in this specific patient group is crucial since this patient group has the potential to return to competitions 6 weeks after injury, unlike patients without hyperlaxity.

Are critical shoulder angle and acromion index correlated to the size of a rotator cuff tear.

PURPOSE: Scapular morphology is an extrinsic factor playing role in rotator cuff tear (RCT) etiology. The objective of this study was to evaluate the relationship between critical shoulder angle (CSA) and acromion index (AI) with partial-bursal side and full thickness RCT and the size of the RCT. HYPOTHESIS: The hypothesis was that CSA and AI would be greater in partial bursal-side RCT and full-thickness RCT patients and would increase with the size of the RCT. METHODS: This retrospective study assessed 218 patients who had standard shoulder radiographs and magnetic resonance imaging. Patients were divided into three groups: intact rotator cuff (68), partial bursal-side RCT (34) and full-thickness RCT (116). In the second part, full-thickness RCT patients were divided into four groups according to RCT size; small (<1cm), medium (1-3cm), large (3-5cm) and massive (>5cm). AI and CSA measurements were evaluated from radiographs. RESULTS: The mean CSA was 32.8̊ in control group, 34.3̊ in partial group and 36.9̊ in full-thickness group. The mean AI was 0.66, 0.68 and 0.72 respectively. Significant difference was found in AI and CSA between full thickness RCT and intact RC group (p<0.01), and partial RCT and full thickness RCT group (p<0.05) in paired comparisons. In full thickness RCT size groups the mean CSA was 34.2̊, 36.4̊, 39.0̊ and 40.8̊ and mean AI was 0.70, 0.71, 0.73 and 0.79 respectively. Significant difference was found between small-large, small-massive, medium-massive groups for CSA in paired comparisons and between small-massive, medium-massive groups for AI. CONCLUSION: CSA and AI were significantly greater in full-thickness RCT patients and the size of the RCT increased with CSA and AI. The greater CSA and AI could be predictors for larger RCT. LEVEL OF EVIDENCE: III; Cross-Sectional Design; Prognosis Study.

Cemented radial head arthroplasty: Does radiographic loosening have an effect on clinical and functional outcomes? Average 10 years' results.

PURPOSE: The aim of this study was to evaluate the possible effect of radiographic loosening on clinical and functional outcomes, while presenting the mid-term radiographic and functional outcomes of cemented, monopolar RHA applied to patients with comminuted radial head fractures. METHODS: We performed a retrospective study by evaluating the records of patients who were diagnosed in a single center with radial head fractures between 2001 and 2013. Twenty-six patients with comminuted radial head fractures with a mean age of 48.9 and a mean follow-up time of 132.2 months were included. The radiographic evaluation was performed by assessing peri-prosthetic radiolucent lines around the stem to evaluate loosening, while the clinical evaluation was performed by utilizing elbow range of motion (ROM), Mayo elbow performance score (MEPS), Oxford elbow score (OES) and quick-DASH scores. RESULTS: 13 patients (Group 1) with peri-prosthetic stem lucency were defined as radiographic loosening (50%), while the remaining 13 patients (Group 2) were not detected to have stem lucency. One patient in group 1 also had concomitant pain and underwent removal of the prosthesis, while 12 patients (92.3%) remained pain-free. On the latest follow-up visit, there was no significant difference between the groups regarding ROM, MEPS, OES and quick-DASH scores. CONCLUSIONS: Within ten years following surgery, half of the patients with radial head prostheses were noted to show radiographic signs of loosening which did not have any major negative effect in terms of clinical-functional outcomes and quality of life, except requiring the removal of the implant in one patient. LEVEL OF EVIDENCE: Level III.

Reverse total shoulder arthroplasty for failed treatment of proximal humerus fractures.

OBJECTIVE: The aim of this study was to evaluate the functional and radiological outcomes and complications of reverse total shoulder arthroplasty (RTSA) for failed treatment of proximal humerus fractures (FTPHF). METHODS: In this retrospective study, 20 patients (17 female, 3 male; mean age = 71.35 years; age range = 54-81 years) who underwent RTSA for FTPHF between 2012 and 2018 were included. The mean follow-up was 37.85 (range: 24-83) months. Outcome measures included shoulder range of motion, Constant score, ASES (American Shoulder and Elbow Surgeons) score, visual analog scale (VAS). Intra-or post-operative complications were also recorded. RESULTS: The mean anterior flexion and external rotation improved from 37.25°±10.59° and 11.05°±4.79° preoperatively to 105.53° ± 9.33 and 22.37° ± 4.12° postoperatively, respectively (P < 0.01 for both). The mean Constant and ASES scores ameliorated from 21.95 ± 3.57 and 18.15 ± 4.69 preoperatively to 61.7 ± 7.6 and 71.18 ± 4.69 at the final follow-up, respectively (P < 0.01 for both). VAS significantly reduced from 6.83 ± 2.04 preoperatively to 1.79 ± 0.61 at the final follow-up (P < 0.01). None of the patients had major complications or required revision. CONCLUSION: Treatment with the RTSA for the FTPHF seems to be an effective treatment method that can provide satisfactory radiological and functional outcomes with low complication rates. LEVEL OF EVIDENCE: Level IV, Therapeutic Study.

The effect of intravenous tranexamic acid on visual clarity during arthroscopic rotator cuff repair: A randomized, double-blinded, placebo-controlled pilot study.

OBJECTIVE: The aim of this study was to determine the effect of intravenous (IV) tranexamic acid (TRX) use on visual clarity during arthroscopic rotator cuff repair. METHODS: This prospective, randomized, double-blinded, placebo-controlled study was conducted in patients scheduled for an arthroscopic rotator cuff repair. In total, 60 patients were randomly distributed into two groups: control (28 patients: 11 male, 17 female; mean age=53 years, age range=19-65) and TRX (32 patients: 15 male, 17 female; mean age=50, age range=18-69). In the TRX group, the arthroscopy was performed through the bolus IV administration of 10 mg/kg TRX in 100 ml isotonic saline solution. In the control group, the arthroscopy was performed through the bolus IV administration of 100 ml isotonic saline solution. In both the groups, the IV administration was carried out after the induction of anesthesia. At the end of each procedure, the surgeon rated the visual clarity on a scale from 1 to 10. In addition, operation time (minutes), irrigation amount used in operation (lt), and the need of pressure increase because of bleeding were recorded. RESULTS: No adverse effects were seen during the study period. Visual clarity in TRX group was significantly better than the control group (the mean visual clarity scores=8.1/10 (range=7-10) vs 7/10 (range=5-9); p=0.018). The amount of solution was significantly less in the TRX group (10.2 lt (range=3.5-21)) than in the control group (15.8 lt (range=5.8-27); p=0.007, post-hoc power=95.7%), although the operation time was slightly longer in the TRX group (106 minutes (range=50-210)) than in the control group (99 minutes (range=45-165); p=0.24). Moreover, the need for the increase in pressure owing to bleeding was found significantly less in the TRX group (5.8 times (range=(0-9)) than in the control group (9.6 times (range=0-13); p=0.04, post-hoc power=94.5%). CONCLUSION: Preoperative IV TRX administration seems to be effective in improving visual clarity and reducing the need for high pressure and the amount of irrigation fluid during the arthroscopic rotator cuff repair. LEVEL OF EVIDENCE: Level II, Therapeutic study.

A Clinical Comparison of Home-Based and Hospital-Based Exercise Programs Following Arthroscopic Capsulolabral Repair for Anterior Shoulder Instability.

CONTEXT: Ideal rehabilitation method following arthroscopic capsulolabral repair surgery for anterior shoulder instability has not been proven yet. Although rapid or slow protocols were compared previously, home- or hospital-based protocols were not questioned before. OBJECTIVE: The aim of this prospective unrandomized controlled clinical trial is to compare the clinical outcomes of home-based and hospital-based rehabilitation programs following arthroscopic Bankart repair. DESIGN: Nonrandomized controlled trial. SETTING: Orthopedics and physical therapy units of a single institution. PATIENTS: Fifty-four patients (49 males and 5 females) with an average age of 30.5 (9.1) years, who underwent arthroscopic capsulolabral repair and met the inclusion criteria, with at least 1-year follow-up were allocated into 2 groups: home-based (n = 33) and hospital-based (n = 21) groups. INTERVENTIONS: Both groups received identical rehabilitation programs. Patients in the home-based group were called for follow-up every 3 weeks. Patients in the hospital-based group admitted for therapy every other day for a total of 6 to 8 weeks. Both groups were followed identically after the eighth week and the rehabilitation program continued for 6 months. MAIN OUTCOME MEASURES: Clinical outcomes were assessed using Disabilities of Arm Shoulder Hand, Constant, and Rowe scores. Mann-Whitney U test was used to compare the results in both groups. Wilcoxon test was used for determining the progress in each group. RESULTS: Groups were age and gender matched (P = .61, P = .69). Average number of treatment sessions was 13.8 (7.3) for patients in the hospital-based group. Preoperative Disabilities of Arm Shoulder Hand (27.46 [11.81] vs 32.53 [16.42], P = .22), Constant (58.23 [14.23] vs 54.17 [10.46], P = .13), and Rowe (51.72 [15.36] vs 43.81 [19.16], P = .12) scores were similar between groups. Postoperative scores at sixth month were significantly improved in each group (P = .001, P = .001, and P = .001). No significant difference was observed between 2 groups regarding clinical scores in any time point. CONCLUSIONS: We have, therefore, concluded that a controlled home-based exercise program is as effective as hospital-based rehabilitation following arthroscopic capsulolabral repair for anterior shoulder instability.

Functional Outcomes and Complications Following Scapulothoracic Arthrodesis in Patients with Facioscapulohumeral Dystrophy.

BACKGROUND: Facioscapulohumeral dystrophy (FSHD) is an autosomal-dominant myopathy characterized by facial and shoulder girdle muscle weakness with scapular winging. Scapulothoracic arthrodesis is a successful treatment approach for patients with <90° of shoulder elevation. The purpose of the present study was to assess functional outcomes and complications following scapulothoracic arthrodesis in patients with FSHD. METHODS: We retrospectively reviewed the records of 40 patients (64 shoulders) in whom scapulothoracic arthrodesis was performed. To achieve fusion, multiple multifilament cables were used together with autologous bone and allograft bone. Preoperative and postoperative shoulder elevation and abduction; Disabilities of the Arm, Shoulder and Hand (Quick version, qDASH) scores; and pulmonary function were compared. Recorded complications were classified as pulmonary or scapular. RESULTS: The mean age of the patients at the time of the operation was 25.4 years (range, 15 to 60 years), and the mean duration of follow-up was 71.2 months (range, 12 to 185 months). When the preoperative values were compared with those at the latest follow-up, significant improvement was noted in terms of elevation (from a mean [and standard deviation] of 60.6° ± 17.2° to 123.7° ± 26.7°; p < 0.001), abduction (from 52.7° ± 15.8° to 98.8° ± 20.3°; p < 0.001), and qDASH scores (from 34.7 ± 11.4 to 13.3 ± 13.1; p < 0.001). The overall complication rate was 26.6%. There were 7 pulmonary complications (4 pneumothoraxes, 2 pleural effusions, and 1 major atelectasis), and 5 chest tube placements were required. Ten complications (including 3 rib fractures, 1 brachial plexus palsy, 2 cases of implant irritation, 2 nonunions, 1 delayed union, and 1 scapular fracture) were related to the scapular fixation, and 7 revision procedures were required. Scapulothoracic fusion was achieved in all patients but 1, who had a scapular fracture. Pulmonary function tests were performed for 19 patients, and no difference was observed between preoperative and postoperative results. CONCLUSIONS: Scapulothoracic arthrodesis with use of multifilament cables is a successful surgical technique with high fusion rates and low morbidity. Pulmonary complications are common but resolve with careful attention. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Isokinetic Evaluation of Shoulder Strength and Endurance after Reverse Shoulder Arthroplasty: A Comparative Study.

OBJECTIVE: The present study aimed to compare the isometric strength and endurance of shoulder abduction and internal and external rotation between operated shoulders and nonoperated, contralateral shoulders of patients who underwent reverse shoulder replacement due to unilateral rotator cuff tear arthropathy. PATIENTS AND METHODS: With a diagnosis of cuff tear arthropathy, 41 consecutive patients (mean age of 70.8 years; age range, 57 to 84; 36 females, 5 males) who underwent unilateral reverse shoulder arthroplasty were reviewed based on functional and radiological data. In all cases, cuff tear arthropathy was unilateral and contralateral shoulder was asymptomatic, with normal shoulder function. The average length of follow-up was 34 months (range of 12-67). To assess patients' functional level, the Constant score and the Disabilities of the Arm, Shoulder, and Hand (the Quick-DASH) outcome measure were used preoperatively and at the final examination. The primary outcomes of the present study were measurement of isokinetic strength and endurance of shoulder abduction and internal and external rotation using an isokinetic evaluator. RESULTS: Patients exhibited marked improvement in functional level as reflected by a significant increase in the mean Constant score from 38 preoperatively to 65 at the final follow-up (p = 0.03). The functional improvement was supported by a decrease in the mean Quick-DASH from 64 preoperatively to 26 at the final follow-up (p = 0.018). In the comparison of the isokinetic strength and endurance of shoulder abduction, no statistical difference was observed between operated shoulders and contralateral shoulders (p > 0.05). However; the strength and endurance of internal and external rotation were lower in operated shoulders than in contralateral shoulders (p < 0.05). Similarly, there was no statistically significant difference in comparisons of the durability of abduction (p > 0.05); however, the durability of internal and external rotation were significantly lower in operated shoulders (p < 0.05). CONCLUSION: In terms of durability and strength of abduction, similar results with the unaffected shoulder may be accomplished; nonetheless, the surgeon should be aware that durability and strength of rotation would be weak. LEVEL OF EVIDENCE: Level III, Therapeutic Study.

Arthroscopic versus open release of internal rotation contracture in the obstetrical brachial plexus paralysis (OBPP) sequela.

BACKGROUND: Latissimus dorsi (LD) and teres major (TM) tendon transfers are effective surgical procedures to improve shoulder abduction and external rotation for children with obstetrical brachial plexus palsy (OBPP). Open pectoralis major (PM) tendon Z-plasty and arthroscopic subscapularis (SS) release are 2 options for the release of internal rotation contractures to enhance muscle transfers. This study compared the functional results of LD and TM tendon transfers with open PM tendon Z-plasty or arthroscopic SS release. METHODS: The study included 24 patients who underwent LD and TM tendon transfers for OBPP (9 arthroscopic SS release, 15 open PM tendon Z-plasty) with a mean follow-up of 41.33 months (range, 36-60 months) and 47.2 months (range, 36-60 months), respectively. Functional evaluation was made according to range of motion and Mallet scoring system. RESULTS: Shoulder abduction-external rotation degrees and scores in all sections of the Mallet scoring system significantly increased in both groups (P < .001). Postoperatively, the arthroscopic SS release group had significantly better abduction degrees (P = .003), total Mallet scores (P < .001), and superior abduction (P = .043), active external rotation (P = .043), hand-to-head (P = .043), and hand-to-mouth (P < .001) scores for the Mallet scoring system. DISCUSSION: Transfer of LD together with TM tendons combined with one of the internal rotation contracture release procedures yielded good clinical and functional results in patients younger than age 7, regardless of the type of release method. However, arthroscopic SS release, although requiring an experienced surgeon, revealed better clinical and functional outcomes and is considered to be a less invasive and superior method.

Latarjet procedure using subscapularis split approach offers better rotational endurance than partial tenotomy for anterior shoulder instability.

PURPOSE: Latarjet, which is a coracoid bone block procedure, is an effective treatment for anterior shoulder instability with glenoid bone loss. During this reconstructive procedure the subscapularis may be tenotomized or be split to expose the glenoid neck. The aim of this study was to assess the effect of subscapularis management on functional outcomes and internal and external rotation durability and strength. Hypothesis is that the subscapularis split approach will result in better functional results and superior internal rotation strength and endurance. METHODS: The study included 48 patients [median age 30 (range 16-69); 42 males, 6 females], who underwent a modified Latarjet procedure for anterior shoulder instability. There were 20 patients in the subscapularis tenotomy group and 28 patients in the subscapularis split group. The groups were compared isokinetically using a computerized dynamometer for internal and external rotation durability and strength. At the latest follow-up, the patients were evaluated with the American Shoulder and Elbow Surgeons (ASES) and ROWE scores for functional outcomes. RESULTS: At a median follow-up period of 25 (range 12-73) months after the Latarjet procedure, the internal rotation durability was significantly higher in the split group (p = 0.045). However, a statistically significant difference could not be found for internal and external rotational strengths (n.s.). There was also no significant difference between the final ASES and ROWE scores (n.s.). CONCLUSION: Although both approaches offer promising results, the subscapularis split approach appears to provide better internal rotation durability compared to subscapularis tenotomy. Therefore, the subscapularis split approach may be more preferable for the management of the subscapularis muscle during Latarjet procedure. LEVEL OF EVIDENCE: Retrospective cohort study, Level III.

Postoperative analgesia after arthroscopic shoulder surgery: A comparison between single-shot interscalene block and single-shot supraclavicular block.

OBJECTIVES: In arthroscopic rotator cuff surgery for postoperative analgesia opioids, nonsteroid analgesics, and local anesthetics can be used. This study aimed to compare the effectiveness, additional analgesic requirements, patients satisfaction, and complications of single-shot interscalene and supraclavicular blocks. METHODS: After obtaining the ethics committee's approval and informed consent, 50 ASA I-II patients were randomized to either the interscalene (GISB) or supraclavicular (GSCB) group. Preoperatively, patients received an ultrasonography-guided block using 30 ml of 0.5% bupivacaine. In the postoperative period, morphine patient-controlled analgesia was administered as a 0.3-mg/h basal dose and 1-mg bolus dose, with a 20-min lockout time. Postoperative visual analog scale (VAS; 0-10 cm) scores of the patients were evaluated at 4, 8, 12, and 24 h postoperatively; additional analgesic requirements, adverse effects, and complications were recorded. Patient satisfaction (PS) scores were evaluated after 24 h. RESULTS: VAS scores at 4 h were lower in the GSCB group than in the GISB group, and the VAS scores at 8, 12, and 24 h were lower in the GISB group than in the GSCB group, with no statistical significance. Additional analgesic requirements was 28% in the GISB group and 68% in the GSCB group (p < 0.05). Total morphine consumption was lower in the GISB group than in the GSCB group (18.95±9.2 mg vs. 30.6 ± 9.6 mg; p < 0.001). PS scores were higher in the GISB group than in the GSCB group (7.0±1.0 vs. 6.1±0.9; p < 0.01). Adverse effects and complication rates were similar in both the groups. In GISB group, seven patients (28%) had nausea/vomiting, whereas in the GSCB group, 12 patients (48%) had nausea/vomiting. This difference was statistically insignificant. CONCLUSION: Supraclavicular block can be considered as an alternative to interscalene block for arthroscopic shoulder surgery.

Transfer of the lesser tuberosity for reverse Hill-Sachs lesions after neglected posterior dislocations of the shoulder: A retrospective clinical study of 13 cases.

OBJECTIVE: This study aimed to present middle-term functional and radiological outcomes of the transfer of the lesser tuberosity in the management of reverse Hill-Sachs lesions following posterior dislocations of the shoulder. PATIENTS AND METHODS: With a diagnosis of neglected posterior shoulder dislocation (8 locked, 5 recurrent), 13 male patients (age range: 28-72; mean age: 39.3 years) who underwent the transfer of the lesser tuberosity due to reverse Hill-Sachs lesions, were retrospectively reviewed based on functional and radiological data. The etiologies were: epilepsy in 9 patients, a traffic accident in 2 patients, and fall in 2 patients. To assess the patients' functional level, American Shoulder and Elbow Surgeons (ASES) and Constant Scores were used, and the patients' range of motion at the last follow-up was measured. To evaluate the development of arthrosis, the final follow-up control plain radiographs were examined. The average size of the defects calculated from the axial computed tomography sets was 27% (range: 20%-40%). RESULTS: The average length of follow-up was 30 months (range: 12-67 months). At the last follow-up visit, the main ASES and Constant Scores were 78 and 85, respectively, and the average degrees of flexion, abduction, and external rotation were 163°, 151°, and 70° respectively. The concentric reduction was observed postoperatively. CONCLUSION: McLaughlin procedure appears to be a safe and effective method in the treatment of neglected posterior shoulder dislocations with reverse Hill-Sachs lesion. LEVEL OF EVIDENCE: Level IV, Therapeutic study.

Patient state index and cerebral blood flow changes during shoulder arthroscopy in beach chair position / Patient State Index e alterações do fluxo sanguíneo cerebral durante artroscopia do ombro em posição de cadeira de praia

Abstract Background and objectives: The aim of the study were to demonstrate the possible hemodynamic changes and cerebral blood flow alterations in patients who were positioned from supine to beach chair position; and to detect if the position change causes any cortical activity alteration as measured by the 4-channeled electroencephalography monitor. Methods: 35 patients were included. Before the induction, mean arterial pressure and patient state index values were recorded (T0). After the intubation, doppler-ultrasonography of the patients’ internal carotid and vertebral arteries were evaluated to acquire cerebral blood flow values from the formula. In supine position, mean arterial pressure, patient state index and cerebral blood flow values were recorded (T1) and the patient was positioned to beach chair position. After 5 min all measurements were repeated (T2). Measurements of patient state index and mean arterial pressure were repeated after 20 (T3), and 40 (T4) min. Results: There was a significant decrease between T0 and T1 in heart rate (80.5 ± 11.6 vs. 75.9 ± 14.4 beats/min), MAP (105.8 ± 21.9 vs. 78.9 ± 18.4 mmHg) and PSI (88.5 ± 8.3 vs. 30.3 ± 9.7) (all p < 0.05). Mean arterial pressure decreased significantly after position change, and remained decreased, compared to T1. The overall analysis of patient state index values (T1-T4) showed no significant change; however, comparing only T1 and T2 resulted in a statically significant decrease in patient state index. There was a significant decrease in cerebral blood flow after beach chair position. Conclusion: Beach chair position was associated with a decrease in cerebral blood flow and patient state index values. Patient state index was affected by the gravitational change of the cerebral blood flow; however, both factors were not directly correlated to each other. Moreover, the decrease in patient state index value was transient and returned to normal values within 20 min.

Resumo Justificativa e objetivos: Demonstrar as possíveis alterações hemodinâmicas e do fluxo sanguíneo cerebral (FSC) em pacientes que foram posicionados de supinação para cadeira de praia (CP) e detectar se a mudança de posição causa alguma alteração na atividade cortical como mensurado pelo monitor de EEG com quatro canais. Métodos: Foram incluídos 35 pacientes. Antes da indução, os valores da PAM e do IEP foram registrados (T0). Após a intubação, ultrassonografias com Doppler da carótida interna e artérias vertebrais dos pacientes foram avaliadas para adquirir os valores do FSC a partir da fórmula. Em supinação, os valores da PAM, IEP e FSC foram registrados (T1) e o paciente foi posicionado em CP. Após cinco minutos, todas as mensurações foram repetidas (T2). As mensurações do IEP e PAM foram repetidas após 20 (T3) e 40 minutos (T4). Resultados: Houve uma diminuição significativa entre T0 e T1 na FC (80,5 ± 11,6 vs. 75,9 ± 14,4 bpm), PAM (105,8 ± 21,9 vs. 78,9 ± 18,4 mmHg) e IEP (88,5 ± 8,3 vs. 30,3 ± 9,7) (p < 0,05 para todos). A PAM diminuiu significativamente após a mudança de posição e permaneceu diminuída em relação a T1. A análise global dos valores do IEP (T1-T4) não mostrou mudança significativa, mas a comparação de apenas T1 e T2 resultou em redução estatisticamente significativa do IEP. Houve redução significativa do FSC após o posicionado em CP. Conclusão: O posicionado em CP foi associado à diminuição do FSC e dos valores do IEP. O IEP foi afetado pela mudança gravitacional do FSC; no entanto, ambos os fatores não estavam diretamente correlacionados. Além disso, a diminuição do valor do IEP foi transitória e voltou aos valores normais dentro de 20 minutos.

Patient state index and cerebral blood flow changes during shoulder arthroscopy in beach chair position.

BACKGROUND AND OBJECTIVES: The aim of the study were to demonstrate the possible hemodynamic changes and cerebral blood flow alterations in patients who were positioned from supine to beach chair position; and to detect if the position change causes any cortical activity alteration as measured by the 4-channeled electroencephalography monitor. METHODS: 35 patients were included. Before the induction, mean arterial pressure and patient state index values were recorded (T0). After the intubation, doppler-ultrasonography of the patients' internal carotid and vertebral arteries were evaluated to acquire cerebral blood flow values from the formula. In supine position, mean arterial pressure, patient state index and cerebral blood flow values were recorded (T1) and the patient was positioned to beach chair position. After 5min all measurements were repeated (T2). Measurements of patient state index and mean arterial pressure were repeated after 20 (T3), and 40 (T4)min. RESULTS: There was a significant decrease between T0 and T1 in heart rate (80.5±11.6 vs. 75.9±14.4beats/min), MAP (105.8±21.9 vs. 78.9±18.4mmHg) and PSI (88.5±8.3 vs. 30.3±9.7) (all p<0.05). Mean arterial pressure decreased significantly after position change, and remained decreased, compared to T1. The overall analysis of patient state index values (T1-T4) showed no significant change; however, comparing only T1 and T2 resulted in a statically significant decrease in patient state index. There was a significant decrease in cerebral blood flow after beach chair position. CONCLUSION: Beach chair position was associated with a decrease in cerebral blood flow and patient state index values. Patient state index was affected by the gravitational change of the cerebral blood flow; however, both factors were not directly correlated to each other. Moreover, the decrease in patient state index value was transient and returned to normal values within 20min.

[Patient state index and cerebral blood flow changes during shoulder arthroscopy in beach chair position]. / Patient State Index e alterações do fluxo sanguíneo cerebral durante artroscopia do ombro em posição de cadeira de praia.

BACKGROUND AND OBJECTIVES: The aim of the study were to demonstrate the possible hemodynamic changes and cerebral blood flow alterations in patients who were positioned from supine to beach chair position; and to detect if the position change causes any cortical activity alteration as measured by the 4-channeled electroencephalography monitor. METHODS: 35 patients were included. Before the induction, mean arterial pressure and patient state index values were recorded (T0). After the intubation, doppler-ultrasonography of the patients' internal carotid and vertebral arteries were evaluated to acquire cerebral blood flow values from the formula. In supine position, mean arterial pressure, patient state index and cerebral blood flow values were recorded (T1) and the patient was positioned to beach chair position. After 5min all measurements were repeated (T2). Measurements of patient state index and mean arterial pressure were repeated after 20 (T3), and 40 (T4)min. RESULTS: There was a significant decrease between T0 and T1 in heart rate (80.5±11.6 vs. 75.9±14.4beats/min), MAP (105.8±21.9 vs. 78.9±18.4mmHg) and PSI (88.5±8.3 vs. 30.3±9.7) (all p<0.05). Mean arterial pressure decreased significantly after position change, and remained decreased, compared to T1. The overall analysis of patient state index values (T1-T4) showed no significant change; however, comparing only T1 and T2 resulted in a statically significant decrease in patient state index. There was a significant decrease in cerebral blood flow after beach chair position. CONCLUSION: Beach chair position was associated with a decrease in cerebral blood flow and patient state index values. Patient state index was affected by the gravitational change of the cerebral blood flow; however, both factors were not directly correlated to each other. Moreover, the decrease in patient state index value was transient and returned to normal values within 20min.

Acute traumatic posterior fracture dislocation of the elbow in pediatric patients: impact of surgery time and associated fractures on outcome.

This study assessed the effect of the time interval from initial injury to surgery and the presence of associated fracture on functional outcomes after acute posterior elbow fracture dislocation. Twenty-six pediatric patients were evaluated with respect to operation time point (within 24 h vs. later) and associated fracture retrospectively. The Mayo Elbow Performance Index (MEPI) score was used to assess functional results. The MEPI score was 91 (80-100) in patients with one associated fracture and 83 (75-95) (P=0.02) in patients with more than one associated fracture. The MEPI score in patients treated within 24 h was 90.3 (75-95) and in those treated later than 24 h, it was 88.6 (75-100) (P=0.6). Treatment time (within 24 h vs. later) does not affect outcomes, but increasing numbers of associated injuries affect outcomes negatively. Level of study: Level IV case series.

Surgery in patients with von Willebrand disease.

Von Willebrand disease (vWD) is the most common inherited bleeding disorder. The biggest challenge in the management of vWD is the difficulty in performing surgical procedures because of bleeding. Treatment guidelines recommend the use of pure von Willebrand factor or von Willebrand factor/factor VIII (vWF/FVIII) concentrate in patients with type 2 or type 3 vWD undergoing surgery, in patients with type 1 vWD undergoing surgery who are unresponsive, and in patients for whom desmopressin acetate is contraindicated. However, there is no consensus on the dosage and optimum levels of these factors to date. The aim of this study was to evaluate the perioperative management of patients with vWD during surgical procedures. Data pertaining to surgical procedures performed at our center from 2003 to 2014 were analyzed retrospectively. All operations, except one appendectomy, were elective, and a plan for the management of hemostasis was prepared for each patient. During this period, 37 surgical procedures (major, minor, and dental) were performed in 23 patients with vWD. Complications occurred in four out of 37 procedures (10.8%). No deaths or life-threatening bleeding occurred during any of the operations and no thromboembolic events were observed. The results from this retrospective study indicate that surgery can be safely performed by providing adequate and timely hemostasis during and after the procedure in patients with vWD. Perioperative and postoperative bleeding complications are rare when patients are closely and carefully monitored.

Is Coonrad-Morrey total elbow arthroplasty a viable option for treatment of distal humeral nonunions in the elderly?

OBJECTIVE: The purpose of this study was to evaluate the functional and radiological results of semiconstrained Coonrad-Morrey total elbow arthroplasty for distal humeral nonunions in the mid-term period. METHODS: Seven patients were treated with Coonrad-Morrey total elbow arthroplasty for distal humeral nonunion. All patients were female, and the mean age was 65.6 years (range: 64-68 years). Patients were followed for at least 5 years, and the mean follow-up time was 73 months (range: 63-84 months). Anteroposterior and lateral radiographs at preoperative and early postoperative period of the joint replacement and latest follow-up were used to detect postoperative radiological changes in terms of loosening. The Mayo Elbow Performance Index (MEPI) and Q-DASH Score were used for functional evaluation. RESULTS: At the latest follow-up, joint stability had been achieved in all 7 patients. Six patients (85.7%) were pain free. The mean range of motion was 30° (range: 0-60°) preoperatively, and this improved to 90.7° (range: 60-110°) at the latest follow-up (p<0.05). Five patients (71.4%) had excellent or good outcomes on the MEPI. The mean Q-DASH Score was improved from 93.2 to 34.5 (p<0.01). Two humeral components had aseptic loosening, and 1 of them was revised. CONCLUSION: Semiconstrained total elbow arthroplasty can be a reliable choice of treatment if other internal fixation methods fail. Significant pain relief and improvements in elbow function and stability can be achieved with semiconstrained elbow arthroplasty in patients with distal humeral nonunion.

Can Normal Fracture Healing Be Achieved When the Implant Is Retained on the Basis of Infection? An Experimental Animal Model.

BACKGROUND: Infection after open fractures is a common complication. Treatment options for infections developed after intramedullary nailing surgery remain a topic of controversy. We therefore used a rat fracture model to evaluate the effects of infection on osseous union when the implant was maintained. QUESTIONS/PURPOSES: In a rat model, (1) does infection alter callus strength; (2) does infection alter the radiographic appearance of callus; and (3) does infection alter the histological properties of callus? METHODS: An open femoral fracture was created and fixed with an intramedullary Kirschner wire in 72 adult male Sprague-Dawley rats, which were divided into two study groups. In the infection group, the fracture site was contaminated with Staphylococcus aureus (36 animals), whereas in the control group, there was no bacterial contamination (36 animals). No antibiotics were used either for prophylaxis or for treatment. We performed biomechanical (maximum torque causing failure and stiffness), radiographic (Lane and Sandhu scoring for callus formation), and histologic (scoring for callus maturity) assessments at 3 and 6 weeks. The number of bacteria colonies on the femur, wire, and soft tissue inside knee were compared to validate that we successfully created an infection model. The number of bacteria colonies in the soft tissue inside the knee was higher in the infection group after 6 weeks than after the third week, demonstrating the presence of locally aggressive infection. RESULTS: Infection decreased callus strength at 6 weeks. Torque to failure (299.07 ± 65.53 Nmm versus 107.20 ± 88.81, mean difference with 95% confidence interval, 192 [43-340]; p = 0.007) and stiffness at 6 weeks (11.28 ± 2.67 Nmm versus 2.03 ± 1.68, mean difference with 95% confidence interval, 9 [3-16]; p = 0.004) both were greater in the control group than in the group with infection. Radiographic analysis at 6 weeks demonstrated the fracture line was less distinct (Lane and Sandhu score of 2-3) in the infection group and complete union was observed (Lane and Sandhu score of 3-4) in the control group (p = 0.001). Semiquantitative histology scores were not different between the noninfected controls and the rats with infection (score 10 versus 9). CONCLUSIONS: Retaining an implant in the presence of an underlying infection without antibiotic treatment leads to weaker callus and impedes callus maturation compared with noninfected controls in a rat model. Future studies might evaluate whether antibiotic treatment would modify this result. CLINICAL RELEVANCE: This model sets the stage for further investigations that might study the influence of different interventions on fracture healing in implant-associated osteomyelitis. Future observational studies might also evaluate the histological properties of callus in patients with osteomyelitis.

Nonoperative treatment of frozen shoulder: oral glucocorticoids.

PURPOSE: The aim of this study was to report our results of glucocorticoid therapy combined with pregabalin and a home exercise program in patients with frozen shoulder. METHODS: Thirty-three patients (seven males, 26 females; mean age 52, range 43-71) diagnosed with primary idiopathic frozen shoulder were included in the study. Secondary causes and systemic diseases related to frozen shoulder were excluded. Administration of 0.5 mg/kg/day methylprednisolone was halved each week and ceased at the end of first month. Pregabalin, paracetamol and proton pump inhibitor was also included in the treatment. Physical therapy as a home program was initiated as the pain subsided. Patients were evaluated using the Constant, DASH and ASES scores in the sixth week and first year. Pain was evaluated with VAS and range of motion at each visit. RESULTS: Patients were followed up for an average period of 21 months (range 12-37). No adverse effect related to glucocorticoid therapy was observed during the treatment. The DASH, ASES and Constant scores improved significantly in the sixth week and first year (p > 0.05). Average range of motion and pain improved significantly every week until full recovery (p > 0.05). CONCLUSION: Glucocorticoid therapy combined with pregabalin and a home exercise program is an effective treatment in the first stage of frozen shoulder.